How to follow a level 6 soft and bite-sized diet?

According to the International Dysphagia Diet Standardisation Initiative (IDDSI), a level 6 soft and bite-sized diet consists of foods that are soft, tender, and moist, and can be mashed with a fork. Understanding how to follow a level 6 soft and bite-sized diet is crucial for individuals with specific chewing and swallowing challenges, helping to prevent risks like choking and aspiration.

Quick Summary

This guide covers the essentials of a level 6 soft and bite-sized diet, from characterizing approved foods and explaining the fork pressure test to listing foods to avoid and offering preparation tips for tasty, safe meals. It is tailored for those who require specific food textures for safe consumption.

Key Points

• Particle Size is Key: Adhere strictly to the adult 1.5cm x 1.5cm particle size to minimize choking risks.

• Test Food with a Fork: Use the fork pressure test to verify that food is sufficiently soft and moist before eating or serving.

• Embrace Soft and Moist Textures: Prioritize foods that are naturally soft or cooked until tender, and always add a thick sauce, gravy, or custard to prevent dryness.

• Avoid High-Risk Foods: Steer clear of hard, tough, sticky, chewy, stringy, and crumbly items, along with skins, seeds, and bones.

• Prioritize Nutrition: Fortify meals and snacks with extra calories and protein using full-fat products, creams, or nutritional supplements if appetite is poor.

• Consult a Professional: Always follow the guidance of a Speech and Language Therapist or dietitian, especially if you notice any changes in swallowing.

What is the IDDSI Level 6 Soft and Bite-Sized Diet?

The IDDSI framework provides a standardized system for classifying modified food textures and drink thickness for individuals with chewing and swallowing difficulties (dysphagia). Level 6, known as "Soft and Bite-Sized," is a critical stage that bridges the gap between pureed diets and regular foods. It is recommended for individuals who can chew but may struggle to bite off larger pieces of food safely due to conditions such as missing teeth, poor-fitting dentures, or muscle weakness in the mouth. The primary goal is to provide a balanced diet that is easy to chew, gather into a bolus with the tongue, and swallow without significant risk.

Key characteristics of a Level 6 diet include:

• Particle size: Food is cut into small, manageable pieces, typically no larger than 1.5 cm by 1.5 cm for adults, which is approximately the width of a standard fork.
• Softness and moisture: Foods are soft, tender, and moist throughout. They should not be dry, hard, crumbly, or crispy.
• No separate thin liquids: Any sauces, gravies, or moisture should be thick enough to hold the food together, without dripping or separating.
• Chewing required: This diet still requires moderate chewing, but a knife is not needed to cut the food.
• Mashed easily: The food should be soft enough to be easily mashed or broken down with pressure from a fork or spoon.

Checking Food Texture: The Fork Pressure Test

To ensure your food is safe and meets the IDDSI Level 6 standard, use the simple fork pressure test before serving. This test verifies that the food is both soft enough and tender enough for consumption.

1. Take a small sample of the food you have prepared.
2. Press down on the food with the side of a fork until your thumbnail blanches (turns white).
3. Remove the fork. The food should be completely squashed and should not return to its original shape.
4. The fork should also be able to easily cut or break the food into smaller pieces.

This method helps eliminate guesswork and provides confidence that the meal is safe to eat.

Approved Food Groups for a Level 6 Diet

Planning a nutritious and varied diet at Level 6 is important for maintaining health and enjoyment of food. The key is to select foods that can be cooked and prepared to the required soft and bite-sized texture.

Protein Foods

• Meats: Tender, slow-cooked meats like casseroles, stewed beef, pulled pork, or shredded chicken, all cut into small, 1.5cm pieces. Ensure plenty of thick gravy or sauce for moisture.
• Fish: Flaked, boneless fish cooked until very soft, such as cod or salmon with a cheese or white sauce.
• Eggs: Scrambled, poached, or boiled and chopped eggs. Egg salad is also suitable.
• Legumes: Well-cooked, softened beans and lentils used in thick soups or stews.
• Tofu: Soft tofu cut into bite-sized pieces.

Fruits and Vegetables

• Cooked Vegetables: Softly boiled, steamed, or roasted vegetables like carrots, sweet potatoes, broccoli, or cauliflower, cut into small pieces.
• Soft Fruits: Ripe, peeled, and diced fruits such as bananas, peaches, mangoes, kiwi, and seedless melon. Tinned or stewed fruit is also a good option.
• Avocado: Mashed avocado or guacamole.

Grains and Starches

• Cereals: Fully softened cereals like oatmeal, porridge, or Weetabix soaked in milk with excess liquid drained.
• Pasta: Well-cooked pasta such as macaroni or lasagna, served with a thick, smooth sauce.
• Rice: Soft, well-cooked rice served in a thick, smooth sauce to prevent separation.
• Potatoes: Mashed potatoes with butter and cream, or soft-boiled potato cubes with gravy.

Dairy and Desserts

• Dairy: Yogurt (without nuts or bits), cottage cheese, soft ricotta, and cream cheese. Small, grated pieces of soft cheese can be melted into sauces.
• Desserts: Smooth puddings, custard, mousse, and soft, moist cakes with cream or custard. Ensure no nuts or dried fruit are present.

Foods to Avoid on a Level 6 Diet

Some foods present a high risk and must be avoided to ensure safety. These include:

• Hard, tough, or dry items: Nuts, seeds, popcorn, dry toast, crisps, hard biscuits, or dry cakes.
• Chewy or sticky textures: Toffees, marshmallows, dried fruit, tough meat, or bread crusts.
• Fibrous or stringy foods: Pineapple, celery, runner beans, rhubarb, or stringy meat.
• Mixed consistencies: Cereal in thin milk, soups with large chunks, or fruits with thin, watery juice.
• Skins, pips, and bones: The skins of fruits and vegetables, pips, seeds, and any bones or gristle from meat or fish.
• Crumbly foods: Pie crusts, crumble topping, or dry bread.

How to Prepare Nutritious Meals for a Level 6 Diet

Proper preparation is key to making level 6 meals both safe and appealing.

• Cook until very tender: Use slow-cooking methods for meats and ensure vegetables are boiled or steamed until soft.
• Chop consistently: Invest in a good chef's knife or food chopper to ensure all pieces are uniform and within the 1.5cm size limit.
• Add moisture generously: Use thick, smooth sauces, gravies, creams, or custards to moisten dishes. This helps bind the food together and makes it easier to swallow.
• Fortify for nutrition: If weight loss or poor appetite is a concern, fortify foods with extra calories and protein. Add skim milk powder to milk, grated cheese to mashed potatoes, cream to soups, or smooth nut butter to shakes.

Sample Level 6 Meal Plan

Meal	Description
Breakfast	Porridge or softened wheat biscuits with full-fat milk and a touch of honey. Diced, ripe peaches with thick yogurt.
Lunch	Soft pasta with a thick meat bolognese sauce. Side of steamed, diced carrots.
Snack	Vanilla yogurt or rice pudding.
Dinner	Shepherd's pie with a topping of creamy mashed potato and tender minced meat in thick gravy. Serve with mushy peas.
Dessert	Chocolate mousse or egg custard.

Level 6 vs. Level 5 (Minced and Moist): A Comparison

Feature	IDDSI Level 6 (Soft and Bite-Sized)	IDDSI Level 5 (Minced and Moist)
Chewing	Requires moderate chewing.	Requires minimal chewing.
Food Texture	Soft, tender, and moist lumps up to 1.5cm for adults.	Minced or finely chopped food particles no larger than 4mm, well-moistened.
Liquids	Thick, smooth sauce or gravy holds food together; no separate thin liquid.	Thick, smooth sauce or gravy holds food together; no separate thin liquid.
Fork Test	Food mashes and breaks apart with fork pressure.	Food mashes easily with fork pressure.
Preparation	Requires cooking until tender and careful cutting to size.	Requires mincing or finely chopping all ingredients.

Conclusion

Following a level 6 soft and bite-sized diet is a critical and safe way for many individuals with dysphagia to enjoy a wide variety of foods. By understanding the specific requirements for food texture, implementing the fork pressure test, and learning which foods to include and avoid, you can manage this diet effectively. Always remember that proper preparation is not just about taste but, more importantly, about safety. If you have any concerns or notice changes in swallowing ability, consult a healthcare professional, such as a Speech and Language Therapist or a registered dietitian, to ensure you are on the correct and safest diet for your needs. For more information, visit the International Dysphagia Diet Standardisation Initiative (IDDSI) website.

Frequently Asked Questions

What is the purpose of the IDDSI Level 6 diet?

The purpose is to provide a diet for individuals with mild dysphagia or chewing problems who can manage bite-sized, soft food, but cannot safely bite into larger, harder pieces.

How do I check if my food is soft enough for Level 6?

Perform the fork pressure test: press a fork onto the food until your thumbnail blanches. The food should be completely squashed and not return to its original shape.

Can I eat bread on a Level 6 diet?

Most plain white bread is not advised due to its crumbly texture. However, some healthcare professionals may approve softened, crust-removed bread with a moist topping, or bread soaked in a solution.

How can I add more calories to meals if I have a small appetite?

Incorporate full-fat products like milk, cream, and cheese. Add butter or mayonnaise to potatoes and vegetables. Consider making milkshakes or smoothies with added protein powder or nut butters.

Are fruits and vegetables allowed on this diet?

Yes, but they must be prepared correctly. Use soft, ripe, peeled, and diced fresh fruits or canned/stewed fruits. Vegetables should be cooked until very tender, peeled, and cut to the bite-sized limit.

What kind of liquids can I have with a Level 6 diet?

The liquid consistency is determined by your healthcare provider. If you have a separate thickened fluid recommendation, any sauces, gravies, or drinks must be thickened accordingly. Any moisture with the food should be thick and not separate.

What should I do if my swallowing gets worse?

If you notice changes like coughing, a 'gurgly' voice, or fatigue while eating or drinking, stop and immediately contact your Speech and Language Therapist for reassessment.

Can I use convenience foods on this diet?

Some convenience foods like ready-made custards, canned fruit, or certain ready meals (e.g., cottage pie) can be suitable, but always check the texture and particle size to ensure they meet Level 6 standards.

How can I make meat tender enough for this diet?

Use slow-cooking methods like stewing or casseroling. For roasting, ensure the meat is tender and shredded or finely diced, then served in plenty of thick gravy.